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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT s 1601 E. HAZEL T ON AVE., STOCKTON, CA p Al V-D Telephone (209) 466-6781 +R1GC+ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �9* (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein n�i ation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862for well/pump and the Rule lsjf�i Joaquin Local Health District. VMA t r Job Address Z a7 Z O �' �� City S7�,-e- Lot Size _ PM Owner's Name C� ��" Address Phone�`�¢�j33 G 7 0 eo Contractor's Name d �� 44 4' Ase No. DG !i Phone 47,647,61 L7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ` ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing Specifications X] J4 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout W ❑ irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 100 State Work Done Weil Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units:_ Number of bedrooms Character of soil to a depth of 3 feet: _Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments l� PKG. TREATMENT PLT. ❑ Method of Disposal (6 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line R SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and ...� Cr a aU of e Sin Joaquin Local Health District. 1 A vb lifi'+�i`or tli`940 ag'e�1t�Signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not emp1J0Wb06"hlir{Aikh!In4anner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature clL fligp�rorlp't oertify:that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of CaR43mia." The applicant must call for all squired ins ons. Complete drawing on reverse side.�'1 _ Signed Title: t44- /—OFMQ Date: F EP,4RTMENT USE ONLY Appli ion Accepted by -c�-� - � Date �( rea Pit or Grout Inspection by Date Final Inspection by `�� Date/ Additional Comments: — — ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH + EH 13-24 IREV.101&31- 3�- 3 ! -� ,�. j�g 3I EH 14-28 �a r